Journal Issue: Vol.7, No.3 - July 2008

Editorial

Dr David Joske, Head of Haematology, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands WA 6009
Founder and Chairman, SolarisCare Foundation
e-mail: david.joske@health.wa.gov.au
This work is an abbreviated version of an address to The Australian Integrative Medicine Association Conference, Leura NSW, August 2007. It was published in full in the conference proceedings.
Australians live in a cancer-phobic society, perhaps best exemplified by the well-intentioned slogan "Cancer is a word, not a sentence". The media tend to portray cancer in simplistic and subjective terms that do a great disservice to Australians with cancer. A survey of eighteen newspapers, examining 5,474 articles about cancer in the United Kingdom in 1999 found that all cancers were portrayed as one disease; articles focused on the shock of diagnosis, the horrible treatment, implied the outcome was known after three months and tended to portray individuals with cancer as 'warriors' (especially if famous!) or 'victims' (Jane Maher, Personal Communication). When The Honourable Jim Bacon, then Premier of Tasmania, publicly announced in February 2004 that he had lung cancer, he was inundated with well-wishing communications sent by post, e-mail and other means. They included, 157 items of correspondence recommending a wide variety of complementary and alternative medicines (CAMs; Lowenthal, 2005). Cancer is much feared and widely discussed.
The cancer reality is indeed sobering. In 2001 there were 88,398 new cancer cases in Australia and 36,319 deaths due to cancer, representing 257,458 potential years of life lost to the community. One in three men and one in four women will be diagnosed with some form of cancer. In 2001, A$2.7 billion were spent on cancer, including $250 million on cancer research (Cancer in Australia 2001).
Is it possible, with access to the latest developments in cancer medicine (including some stunning breakthroughs in leukaemia), that mainstream medicine in Australia has come to focus too much on the curing and not enough on the healing? Curing represents eradication of disease, where healing represents achieving the best possible physical and psychological health in an individual, even if disease such as cancer can not be eradicated. In focusing on curing, unnecessary distress and grief may be engendered for the patient, their carers and relatives. We must 're-humanise' health care. Just because we have grown up with a high-technology, high-pressure, short-appointment, harried-health-professional face of modern health care,it doesn't mean we should accept this is the best way to go.
And we aren't. This is at least in part why Australians, with cancer, like their brothers and sisters world-wide, are turning to CAM:-- for a more humanistic approach. Between 40 and 70% of people with cancer use CAM in some form(Ernst & Cassileth 1998; Molassiotis etal 2005); the figure rises to 90% in the US if prayer is included! (Yates et al 2005). And although this represents an attempt to wrest control of a terrible situation - our business leaders would commend such a pro-active step - patients were and are often humiliated for doing this. Cancer patients will continue to turn to complementary and/or alternative medicine (CAM). These are vulnerable patients and the mainstream medical community is rightly skeptical of snake-healer treatments and quacks who promise a lot, often at great expense, and stand in the way of patients accessing effective treatment. Nevertheless, mainstream medicine, with its bio-technological and reductionist approach,studying diseases and populations, often fails to provide a humane situation where an individual can respond to their illness in a positive and self-empowering way. Turning to complementary medicine is one way that people with cancer can start to take control of the situation and do something themselves, as opposed to being told what to do and what to take and how to feel. People with chronic illness, including cancers, should be encouraged to do this and thus the mainstream community must now have some understanding of CAM. We need to know which CAM modalities are appropriate, and for which there is evidence of efficacy in controlling symptoms, versus those that are harmful.
Six years ago, I decided to buy into the CAM controversy and make selected therapies available in a cancer support centre in my teaching hospital; the alternative was to feel there would always be a barrier between my patient and me; this was not acceptable. My response as a physician and a person to a gnawing and growing feeling that more support was needed for my patients was to set up the SolarisCare Foundation Cancer Support Centre in a mainstream teaching hospital (formerly the Brownes Cancer Support Centre). It provides safe and supervised access to complementary therapies, cancer advice and information, within, if slightly apart from, the teaching hospital setting. Since its inception, the Centre has had between 100-200 visitors a week, of whom about half are cancer patients and their carers and who access complementary therapies.There are minimal paid staff and at present around fifty volunteer 'meet-and-greet' staff and 50 complementary therapists. The decision was made, based on a review of the literature (Joske et al 2006), to concentrate upon massage-based or psychological interventions. Medico-legal risk was minimised with careful selection of do's and don'ts for the therapists, with third party insurance supplied by the hospital itself, and with careful selection and four weeks observation of therapists prior to commencing treatments in the Centre. A second centre opened in July 2008, at a private hospital with a large cancer centre, and a 'Chemo Club' has been available since November 2006 at a local gymnasium offering supervised resistance training for chemotherapy patients. All treatments and the Chemo Club are free. Uncontrolled and blunt quality of life and symptom distress data was collected over five years using a modified instrument adapted from the palliative care setting.
Very briefly, data has been collected in over 1000 cancer patients (Joske et al 2005). 80% of them are women: 55% of those with cancer have breast cancer; 20% of the visitors are carers of patients with cancer. The data shows small, but measurable, improvements in quality of life, and reduced cancer symptoms,over the course of six free CAM sessions. The main symptoms that have shown a response to this approach are pain and fatigue, two of the most troublesome problems in cancer patients. More research is needed before we can definitively state that this is due to the Centre itself. However, anecdotal reports from patients suggest improved compliance with mainstream treatment ("I used to dread coming to the hospital for chemo, until I started using the Centre for a massage session afterwards"). Amongst my own patients, I sometimes see a turnaround in psychological demeanor, after a visit to the Centre, to a more pro-active and on-side approach with the mainstream treatment. We also find that the Centre and the Chemo Club provide a sense of community for socially isolated cancer patients (sometimes from the very wealthiest suburbs!), and a tangible focus point for the wellspring of support from the community at large who want to help. Evidence that complementary therapies alter cancer survival at this stage is lacking, and that is not really the point.
Thus, the availability of safe, supervised complementary therapies may have much to offer an over-stressed health system and Australians battling through the cancer journey: non-pharmacological ways to help control cancer symptoms and treatment side effects such as pain, fatigue and nausea; a chance for cancer patients to be pro-active and empowered; and a way to harness a large groundswell of community goodwill to help.
Modern medicine will deliver more improvements and breakthroughs. Many exciting new areas of research have been opened in population genomics, proteomics and micro-array, to name just a few. Whilst these are eagerly awaited, the challenge for all of us providing mainstream health care is to maintain a humanistic people-centred approach. Some very ancient forms of healing, discredited for centuries, may offer one way to re-humanise health care, empower patients and ensure a human face remains on our health care system. Hippocrates knew the difference between curing and healing;he said: "Cure occasionally, relieve often, comfort always".
REFERENCES
Lowenthal, R. Public illness: how the community recommended complementary and alternative medicine for a prominent politician with cancer. Med J Aust 2005; 183:576-579.
Cancer in Australia 2001. Australian Cancer Institute of Health and Welfare and Australasian Association of Cancer Registries 2004. AIHW Cat. No. 213 Canberra.
Ernst E, Cassileth BR. The Prevalence of Complementary/Alternative Medicine in Cancer. Cancer. 1998; 83: 777-782
Molassiotis A, Fernandez-Ortega P, Pud D et al. Ann Oncol.2005 Apr;16(4):655-63. Epub 2005 Feb 2.
Yates JS, Mustian KM, Morrow GR, et al. Prevalence of complementary and alternative medicine use in cancer patients during treatment. Support care Cancer 2005 Oct; 13(10):806-11. Epub 2005 Feb 15.
Joske DJL, Rao A, Kristjanson L. Critical review of Complementary therapies in haemato-oncology. Int Med J 200636 479-586.
Joske DJL, Popescu A, Kristjanson LJ, Wallis K, Oliver D. Complementary medicine therapies in a teaching hospital. In Cohen M. (Editor) The Art and Science of Holistic Health AIMA, Clayton, 2005:146-153.

Profile

Prof. Stephen Clarke
Prof. Stephen Clarke, a world renowned expert in the field of Cancer Pharmacology and Oncology, is presently working as Professor of Medicine in the Sydney Cancer Centre, one of Australia's leading cancer centres.
Prof. Stephen Clarke is a medical oncologist and translational cancer researcher based at the University of Sydney in NSW, Australia. Prof. Clarke obtained his medical degree (MB BS) through the University of Sydney in 1983. He completed an FRACP in Medical Oncology in 1990. From 1991-1994, Prof. Clarke worked in the Drug Development Unit of the Institute of Cancer Research/Royal Marsden Cancer Hospital in Sutton, Surrey, UK. He obtained a PhD in cancer pharmacology from the University of London. He returned to Australia in 1994. His clinical practice is at the Sydney Cancer Centre, where he has a major interest in colorectal cancer. Prof. Clarke is also Head of the Cancer Pharmacology Unit at the Sydney Cancer Centre, where he has undertaken extensive research on predictors of toxicity for a range of cytotoxic drugs including raltitrexed, pemetrexed, irinotecan, docetaxel and capecitabine. He is also involved in the assessment of proteomic predictors of outcome in patients with colorectal cancer. In addition, his laboratory has made major findings in relation to the impact of cancer associated inflammation on chemotherapy toxicity and survival. He has been an invited speaker at numerous national and international meetings and has over 100 publications in peer-reviewed journals. Prof. Clarke has been a reviewer for many journals and is on the editorial boards of Australian Prescriber and the Asia Pacific Journal of Oncology. He is the Oncology Adviser for the Australian Department of Veterans' Affairs, and is a member of the Australian Drug Evaluation Committee (ADEC) and the Repatriation Pharmaceutical Reference Committee.

Manuscript

Dr Pam McGrathInternational Program of Psycho-Social Health Research (IPP-SHR),Central Queensland University Visit Website

Although the experience of siblings of paediatric patients has received very little attention, the work that does exist indicates that there are significant problems and that the topic needs further exploration. As a contribution to furthering this area of research, the present paper presents findings on siblings experience from a study examining the impact of the diagnosis and treatment for childhood Acute Lymphoblastic Leukaemia (ALL) from the perspective of all family members. In particular, the effect of relocation upon the sibling, emotions and relationships between sibling and parent will be presented. The findings indicate that siblings are a vulnerable group who report feeling very left out because of the enormous demands place on their families during the intense and prolonged medical drama associated with treatment for ALL.

Bone and soft tissue tumours are relatively rare and their classification is often found to be difficult by the pathologist. An accurate diagnosis is essential to predict biological behaviour and for therapeutic decision making. Over the last decades our knowledge on the genetic background of the different mesenchymal tumours has evolved, which has led to the 2002 WHO classification integrating pathology and genetics. Approximately 15-20% of bone- and soft tissue tumours has a specific translocation which can be used for diagnosis. The detection of specific translocations is not only important to confirm the diagnosis as was suggested by classical morphology and immunohistochemistry, but is especially useful in those cases with an unusual morphology, immunohistochemical profile or clinical presentation. Translocations can be demonstrated using RT-PCR on RNA isolated from frozen tumour tissue, or FISH on non-decalcified paraffin embedded material. In addition, a small subset of bone and soft tissue tumours is characterized by specific somatic gene mutations, e.g. KIT and PDGFRA mutations in gastrointestinal stromal tumours (GIST), and GNAS1 mutations in fibrous dysplasia and myxoma. Mutation analysis can be useful for diagnosis, and in case of GIST for predicting the response to the tyrosine kinase inhibitor Imatinib (Glivec).

This study adds to previous body of knowledge regarding self-reliance amongst patients in the face of life limiting illness such as cancer. The study used a phenomenological approach through in-depth interviewing a consecutive group of women receiving adjuvant chemotherapy for early breast cancer. The overarching theme reinforces the significance of self-reliance amongst cancer patients in maintaining control over their illness. Although acknowledging the merit in accessing various mechanisms of support, all patients highlighted the importance of being aware that they largely must rely on themselves. Furthermore, in order to overcome treatment side effects, a patient needs the self-determination to succeed. The initial shock and anxiety experienced by many cancer patients following diagnosis is often accompanied patients being overwhelmed with a plethora of information about their condition and it's management. As the treatment regimen proceeds, patients become aware that although they value the support given from various sources, they also need time and space to self-reflect and draw on inner strength in managing their illness.

Dr Xia TingyiDepartment of Radiation Oncology, Air Force General Hospital

Liver cancer, shorten form of primary hepatic carcinoma (PHC), is mainly divided into three types: hepatocellular carcinoma (HCC), cholangiocellular carcinoma and mixed pattern. The incidence is ranked seventh among males and ninth among females in malignancy, and approximately 260,000 patients die of liver cancer worldwide yearly. Liver cancer is the third most frequent malignancy in China and about 110,000 patients die every year, which accounts for 40% of deaths in patients worldwide. In China, which has been a high-risk area for hepatoma, traditionally surgical resection has been the first choice in treatment. However, most of patients with liver cancer also have hepatitis and even hepatic cirrhosis. In nearly eighty percent of patients resection is not feasible because of a variety of reasons. Trans-catheter arterial chemo-embolization (TACE) have been become the first line of treatment for patients who have an unresectable tumor, it has a high short-term efficacy. However, recurrence after TACE treatment is also high and long-term effect of treatment is unsatisfactory. Recently, with rapid development of modern radiotherapy techniques, the outcome has become better than conventional radio-therapies in treating liver cancer. Thus, combined therapy of liver cancer including modern radio-therapy has become popular in recent years and is gaining a lot of attention.

Prof Hassan AmirDepartment of Clinical Anatomy, American University of Antigua, College of Medicine

Ali Akbar Salari

Shokouh Taghipoor

Male breast cancer (MBC) is an uncommon condition. It accounts for less then 1% of all breast cancers and even fewer of all malignancies occurring in men. Between 1992 and 2007, a total of 6673 cancer cases were registered in the pathology department of Shahid Sadoughi University of Medical Sciences and Health Services, Yazd, Iran. Of these 3740 patients (56.46%) were males. Eight of these cases (0.21 %) had breast cancer. The overall male female ratio for MBC was 0.017:1. The mean age of our patients was 63.62 years (SD = 11.63). Stage III and IV disease was observed in 87.5 percent of our patients. Histological analysis revealed that 87.5% of patients had infiltrating ductal carcinoma. Hormone receptor status of the tumor was positive in 87.5 percent of patient for estrogen and progesterone receptor respectively. These observations are discussed for the need for early detection of MBC and national consensus for an evidence based management of MBC in Iran.

Dr Issar NassiriFaculty of Science, Genetics Division, Biology Dept., The University of Isfahan

Mehry Faghihi

Manoochehr Tavassoli

Objective: In this study, we evaluate Juvenile Polyposis syndrome and Cowden Disease mutations in PTEN/MMAC1. We identify and characterize point mutations in PTEN, describe the cancer and other phenotypes associated with each of these mutations, and demonstrate loss of the wild type PTEN allele in the associated tumors.
Methods: The 9 patients included in this study were 8 patients with Juvenile polyposis and 1 patient with Cowden syndrome. PTEN gene was evaluated by means of polymerase chain reaction, single strand conformation polymorphism (SSCP), Heteroduplex mobility assay (HMA) and direct DNA sequencing for detection and characterization of mutations.
Results: According to the results of this research, nucleotide substitutions in PTEN gene were found in 22% (2/9) of patients. The samples were found to be heterozygote for the c.341T>G and c.389G>A mutations. One novel mutation c.341T>Gin Iranian patients with Cowden syndrome was found in this study.
Conclusions: The study of these rare patients could provide insight into PTEN driven tumor genesis and facilitate drug development for millions of cancer patients.

The study involved 50 patients with non-small-cell lung cancer presenting brain metastases. For 24 patients brain metastasis was the initial complaint. All patients had undergone cranial irradiation with a volume of 2000 cGy /g (5 x 400 cGy/g). We assessed a significance of selected prognostic factors (age, sex, number of brain metastases, histopathologic type, time interval between the diagnosis of lung cancer to the occurrence of brain metastasis) for the survival time. The median survival time calculated from the completion of radiotherapy of brain metastasis was 4,42 months. There was no statistically significant correlation between the median survival time and the analysed prognostic factors. Accordingly, further research of some other prognostic factors seems reasonable that would allow to identify patients likely to profit from NSCLC radiotherapy of brain metastasis as far as the survival duration.

There are various radiotherapy modalities that can be chosen for treatment of prostate cancer. The main therapeutic aim of all radiotherapy treatment including prostate is to maximize damage to the tumour and, at the same time, damaging of the surrounding normal tissues must be kept as small as possible. During a process of treatment planning, Tumour Control Probability (TCP) and Normal Tissue Complication Probability (NTCP) are usually assessed to maximize the therapeutic ratio of that treatment modality. However, there is another factor which should also be taken into consideration when the radiotherapy is used for prostate treatment: the risk of developing a fatal second (primary) cancer. There is a number of reports that indicated an elevation in the risk of second cancer of various organs following prostate cancer irradiation, for example, lung, bladder, skin and breast. It was reported in literature that approximately 6 - 7% of prostate cancer patients might develop second cancer following radiotherapy. Although results from some retrospective studies showed that the incidence of second cancers in prostate cancer patients who received radiation treatment is lower than or equal to the baseline, the risk of developing a second cancer in some organs has been significantly elevated. This risk, in association with each available treatment modality for prostate cancer, has not been investigated to this date thoroughly. This review intends to demonstrate such association as found in various reports and also to show a possible approach to assess this risk.